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Home My WebLink About13895-z FOUM NO. 0 TOWN OF SO~?HOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, No Y. BUILDING PER~IT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N~ 13895 Z Date ........................... , 19 Permission is hereby granted ~: ~ /)/~ ~ , ,, .................... at premise~ I~ated at ....~/.~ ...... ~.~ ...................................... County Tax Map No. 1000 Section ...... L.~..../. ........ Block ........ ~ .......... Lot No...~. ................. pursuant to application dated .... ..(~...~...,./..~ ..................... , ,9.~...~.~.,~-~nd approved by the Building Inspector. ~ulldi~g in.~ector Rev. 6/30/80 FORM NO. 6 TOWN OF SOUTHOLD Building Department Town Hall Southold, N.Y. 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructions A. This appllcation must be filled in typewriter OR ink, and submitted iiIl~ to the Building Inspec- tor with the following; for new buildings or new use: 1. Final survey of property with accurate location of all buildings, property lines, streets, and unusual natural or topographic featu res. 2. Final approval of Health Dept. of water supply and sewerage disposal--iS-9 form or equal). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Commercial buildings, Industrial buildings, Multiple Residences and similar buildings and installa- tions, a certificate of Code compliance from the Architect or Engineer responsible for the building. 5. Submit Planning Board approval of completed site plan requirements where applicable. B, For existing buildings (prior to April 1957), Non-conforming uses, or buildings and "pre-existing" land uses: 1. Accurate survey of pZOperty showing all property lines, streets, buildings and unusual natural or topographic features. 2. Sworn statement of owner or previous owner as to use, occupancy and condition of buildings. 3. Date of any housing code or safety inspection of buildings or premises, or other pertinent informa- tion required to prepare a certificate. C. Fees: 1. Certificate of occupancy $5.00 2. Certificate of occupancy on pre-existing dwelling 3. Copy of certificate of occupancy $1.00 4.Vacant Land C.O. $5.00 $15.00 New Building ............. Old or Pre-existing Building ............ Vacant Land ............. Location of Property ...~.] C) f~/~ ~ ~ .~/~. ~..7.1../-.~.cT .~ House No. Street Hamlet Owner or Owners of Property ~ * .f)'? )') /~-r~ k ~)A) ~ ~ County Tax Map No, 1000 Section ............... Block ............. Lot ................ Subdivision ................................. Filed Map No ........... Lot No .............. Permit No. ]. ~ .?~''~ Date of Permit .L/,/..~.°//~.~'-.Applicant ../~ /t-~ ....... _.,,.. .............. Health Dept, Approval /t~ Labor Dept. roval ...... ........................ App .................. Underwriters Approval .. . .~./.~. nnin oard royal ............... .................. Pla g B App ....... Request for Temporary Certificate ..................... Final Certificate ....................... Fee Submitted $ ............................. Construction on above described building and p. ern~t meets all applicable codes and regulations. Applicant. ;'.., .~,, ~ ...... ~. ............ Rev, 10-10-78 FIELD ~NS?~TION FOUNDATION (1st) COMMENTS FOUNDATION (2nd) 2. ROUGH FRAME & PLUMBING INSULATION PER N. STATE ENERGY ~ODE FINAL 0/~ /_,dc ADDITIONAL COMMENTS: 1000771 THE NEW YORK BOARD OF FiRE UNDERWRITERS ~.~ J~e 19, 1985 A~o~ N~, ~.f~ 333011/85 S/S P~ S~t, 200' W/O ~e ~e~ ~o~ Fork ~ & ~t ~.) F~%~t~ N in the following location; ~ B~e~n* ~ ist FI. ~ s.d FC outside ~tlon B~k ~l~-nd Electric COo ~ ~/ P O Box 143 ~ttituck, ~ y 11952 Lic 242 E ~ Per__. 11 This certificate must not be aJtered in any monner; return to the office of *,he Board L~ incorrect. Inspectors mo¥ be identifk, d by the~-,,om~lent/ab. ~1 d,~od 495 South Coun East Patchogoe, NewYork 16) 654-5113 ~72 DATE: ~ BY: NOTIFY dLDING DE 765-18 9 AM TO dNG INSPI 1. AT :~M FOR THE )NS: REQUIRED ROUGH & PLUMBING 4. FINAL ZC)N'qTq~ I(' T!ON MUST BFC ~;-'a-F FOR C O ALL 'R~I¢?ION S'-IALL MEET TFIE )UI~rMr'FITS OF THF N,Y. CONqTRUCTION & ENERGY N'3T RESPONS~BI ~ FOR OR CONSTRUCTION FRn~RS, FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL,: 765-1803 :amined~..."~....., 19 ~.~./'. ,proved ~.."~.. .... , 19~.(. Permit No./..~..??..~. · ·~- ;approved a/c ..................................... (Building Inspector) APPLICATION FOR[BUILDING PERMIT INSZRUCTIO~S Received ........... ,19... Date ............ 19 . a. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with 3 s of plans, accurate plot plan to scale· Fee according to schedule· b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this appli- c, The work covered by this application may not be commenced before issuance of Building Permit. d. Upon approval of this application, the Building Inspector will issued a Building Permit to the applicant. Such permit kept on the premises available for inspection throughout the work. e. No building shall be occupied or used in whole or in part for any purpose whatever until a Certificate of Occupancy save been granted by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or for the construction of buildings, additions or alterations, or for removal or demolition, as herein described. applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and to authorized inspectors on premises and in building for necessary inspections. · Adq~e~... g~.y.x:... ~.A.~ .<. r...--~n .~.. ?.Q~ ...... (Signature of applicant, or name, if a corporation) .x,,. :x.: ..... (Mailing address of applicant) whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. of premises .......................................................................... (as on the tax roll or latest deed) applicant is a corporation, signature of duly authorized ~ffiegn',c~z~'-tg' / (Name and title of corporate ~)~e~2' Builder's License No ........................... Plumber's License No ......................... Electrician's License No ....................... Other Trade's License No ...................... Location of land on which propo~sed work will be done ................ ' .................................. ..... House Number Street Hamlet .¢. County Tax Map No. 1000 Section ............... Block ............... Lot ............... Subdivision ....................." Filed Map No ............... Lot ............... (Name) State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy . . . .~7 ....................................... b. Intended use and occupancy ~' -. .~ .............. 10. 11. 12. 13. 14. Nature of work (check which applicable): New Building ..... ' .....Addition .......... Alteration ....L~.. .... Repair .............. Removal ............ Demolition .............. Other Work ............... i (Description) EstimMed Cost .~ Fee ' ~" (to be paid on filing this application) If dwelling, number of dwelling units .............. Number of dwelling units on each floor ................ Il'garage, number of cars ..... ! ................................................................... If buslness, commercial or mixed occupancy, specify nature and extent of each type of use . .~f',.x~'~c,o~..~../pac,~....... Dimensions of existing structures, if any: Front ............... Rear .............. Depth ............... Height ............... Number of Stones ....................................................... Dimensions of same structure with site. rations or additions: Front ....... %9.~.. ..... Rear .c~ ............ Depth ..... ~" ~ ........... i'. Height ........ .~ ............ Number of Stories... ~ ............ Dimensions of entre new const~ction: Front .......... ~.~.. Rear .... ~,~. ....... Depth ... ~(o ....... Height ....... 7. ...... Number of Stories .... <~ '" ........................... ;22 .............. Size of lot: Front ...... .C7..~.i ........... Rear ......... ~. ~ ....... Depth .~ .~.. ~ ....... Date of Purchase .; ......... ./..~..~. ........... N~e of Former Owner ....-7~f/?.~...7(z>~ A~. 4 ~-~ ..... Zone or use district in which promises are situated ..... 1~5.7. ~. ......................................... Does proposed construction viol,ate any z~ng law, ordinance or regulation: .../'. ........................... Will lot. be regraded ......... I'. ..... ./.~..0. ......... Will excess fill be removed from premises: Yes Name of Owner of premises ..~..~.-~.. ........... Address .Z(~....~..bo% ~.0-4¢¢~. Phone No... '.~ff..8.~ (g~ Name of Architect .......... i ................. Address . .' .~.. ~~.~. Phone No ................ Name of Contractor .. ...... Address ...... Phone No... ?.~'~..-~. PLOT DIAGRAM Locate clearly and distinctly alll buildings, whether existing or proposed, and, indicate all set-back dimensions from property lines. Give street and block ~umber or description according to deed, and show street names and indicate whether interior or coruer lot. STATE OF NEWjt~OR,,K~. ~,X country :S. 8 .,. ~~~ .~ ..~../. ~/~-~ ......... being duly sworn, deposes and says that he is the applicant /[Name of individual sign ina contract) ' above nam/ed. r, agent, e of said owner or owners, and is duly anth. orized to .p. eff.onn or have performed the said work and to make and file this application; that all statements contained m this apphcat~on are true to the best of his knowledge and belief; and that the work will be performed in the manner set forth m the application filed therewith. Sworn to before me this ................... day o ' . ......, Notary Public, ............... County . '...q,O0o Z~'~